Life-sustaining Procedures Research Articles

Factors influencing blood donation

Objective: Blood donation for transfusion as a life-sustaining procedure and an integral part of health system can save lives and improve health of recipients. The aim of the study is to explain volunteer and repeated donation motivating factors and barriers among non-donors in Kabul, Afghanistan. Material and Methods: A comparative cross-sectional study among blood donors and non-donors was conducted using the convenience sampling method in Kabul, Afghanistan in 2020. Data were managed and analyzed using Epi Info version 7.2.1. Results: From a total of 495 study participants, 244 (49%) were donors and 251 (51%) were non-donors with mean age of 33.19 ± 10.1 and 30.31 ± 12.01, respectively. Among donors, 151 (62%) were volunteers and almost half of them, 121 (49%) donated their blood for the 1st time. Willingness of Allah as motivating factor was reported among 171 (70%) of donors and associated with volunteer (χ2 = 44.5, P < 0.001) and repeated donation (χ2 = 10.89, P < 0.001). In addition, rescuing someone’s life was stated by 70 (29%) of donors and only associated with repeated donation (χ2 = 6.01, P < 0.01). As barrier, 120 (48%) of non-donors were concerned on health risks of blood donation with an association found with willingness to donate blood in the future among this category (χ2 = 22.56, P < 0.001). Conclusion: Among volunteer donors, Willingness of Allah was the most prominent motivating factor while along this factor, rescuing someone’s life was mostly reported among repeated donors. Concerns about health risks of blood donation were the highest reported barrier among non-donors in contrast to other barriers. Religious and altruistic factors motivated blood donors to volunteer and repeated donation while misinformation about blood donation hindered this effort. Relying on religious informative channels could help in the development and sustaining volunteer donors’ pool in Afghanistan.

Effects of hospital treatment for congenital heart defects on mother-infant bonding, maternal stress, and parenting

BackgroundInfants with a Congenital Heart Defect (CHD) are now surviving longer with more medical treatment available. Many of these infants undergo hospitalisation for life-sustaining procedures in their first seven months. However, barriers to bonding and the psychological burden on parents while caring for an infant during this time can cause issues for the child-parent relationship. This study aimed to assess links among intensive care factors, maternal stress, the Mother-Infant Bond (MIB) and parenting in these mother-infant dyads. Design and methodsA convenience sample of 148 mothers of CHD children was collected via the Heart Kids Facebook page. An anonymous Qualtrics survey of demographic, hospital experience, MIB, maternal stress and parenting variables was completed retrospectively by mothers of infants with CHD. FindingsThe results indicated that MIB and maternal stress were positively and strongly correlated. Hospital experiences of breastfeeding, staff support required for handling the infant, and prolonged separation were associated with both maternal stress and poorer quality MIB. Maternal past experiences of being parented with care was negatively correlated with maternal stress and MIB difficulties. Time of diagnosis and current parenting style were unrelated to any other variable. Testing the effects of barriers to infant contact and the effect of cardiac surgery highlighted some challenges in assessing these features of care. ConclusionResults indicated that postpartum mothers living through the traumatic experience of supporting their infant while they received treatment for CHD need more individualised psychological and social support to promote positive psychological outcomes for the mother-infant dyad. Practice implicationsHealthcare providers should prioritise mental health support and create opportunities for mothers of infants with congenital heart disease (CHD) to engage with their babies, even in intensive care settings, to reduce stress and improve mother-child bonding. Given that breastfeeding can unexpectedly increase maternal stress in these environments, flexible feeding alternatives and realistic guidance should be offered. Additionally, reflective parenting education programs should help mothers understand how their own upbringing influences their parenting approaches during this critical period.

Challenges and coping strategies when caring for terminally ill persons with cancer: perspectives of family caregivers

IntroductionTerminal illness is an irreversible illness that, without life-sustaining procedures, usually results in death or permanent disability from which recovery is unlikely. When involved, family caregivers are believed to improve health outcomes, such as reduced hospitalization, and establishing a patient’s initial access to professional treatment services. However, caring for a patient with a terminal illness is viewed as one of the most difficult aspects of providing care. This study aimed to identify the challenges, and coping strategies developed by family caregivers to cope with the care of the terminally ill person.MethodsAn exploratory descriptive qualitative approach was used. Twenty (20) family caregivers voluntarily participated in the study from the Korle-Bu Teaching Hospital. Semi-structured interviews were conducted with the participants. The transcribed interviews were then analysed using thematic analysis.ResultsFrom the analysis, three main themes emerged: challenges, coping strategies, and social support. These themes encompassed sixteen subthemes including financial burden, bad health conditions, faith and prayer, and support from health professionals. From the study, both male and female family caregivers narrated that providing care for sick relatives undergoing terminal disease is characterized as a daily duty demanding one’s time and fraught with emotional strain. In addition, even though it was a difficult job, family members who provided care for ailing relatives never gave up, citing responsibility, the importance of family, and religious beliefs as the primary motivations for doing so.ConclusionThe difficulties and demands of family caregiving roles for terminally ill relatives are complex and multifactorial. The findings call for multidisciplinary professional attention for family caregivers and policies that will support their lives holistically.

Comparing AVPU and Glasgow Coma Scales Among Children Seen by Emergency Medical Services.

Consciousness assessment is an important component in the prehospital care of ill or injured children. Both the Glasgow Coma Scale (GCS) and the Alert, Verbal, Pain, Unresponsive (AVPU) scale are used for this purpose. We sought to identify cut points for the GCS to correspond to the AVPU scale for pediatric emergency medical services (EMS) encounters. We conducted a retrospective cross-sectional analysis using the 2019-2022 National EMS Information System data set, including children (<18 years) with a GCS and AVPU score. We evaluated several approaches to develop cut points for the GCS within the AVPU scale and reported measures of performance. Of 6 186 663 pediatric encounters, 4 311 598 with both GCS and AVPU documentation were included (median age was 10 years [interquartile range 3-15]; 50.9% boys). Lower AVPU scores correlated with life-sustaining procedures, including those for airway management, seizure, and cardiac arrest. Optimal GCS cut points obtained via a grid-based search were 14 to 15 for alert, 11 to 13 for verbal, 7 to 10 for pain, and 3 to 6 for unresponsive. Overall accuracy was 0.95, with kappa of 0.61. Intraclass F1 statistics were lower for verbal (0.37) and pain (0.50) categories compared with alert (0.98) and unresponsive (0.78). We developed a cross-walking between the AVPU and GCS scales. Overall performance was high, though performance within the verbal and pain categories was lower. These findings can be useful to enhance clinician handovers and to aid in the development of EMS-based prediction models.

Profile of Blood Donors and Reasons for Deferral at a District Hospital in North Goa

Introduction: A blood transfusion is a life-sustaining procedure in several medical and surgical conditions. It isvital that an adequate inventory of safe blood is established by implementing stringent donor selection criteria andscreening for transfusion transmitted infections by ultrasensitive methods of detection. Despite a huge population,scarcity of blood lingers nationwide and it is important to analyse the varied reasons of deferrals in order to lessenthe deferrals in the future.The aim of this paper is to scrutinise the demographic profile of blood donors and evaluate the patterns andreasons for donor deferral at North Goa District hospital, India.Materials and Methods: This is a retrospective study carried out at the Blood Centre , North Goa Districthospital,India,. All those who registered for donation between June 2022 till May 2023 were included in the study.The donors were screened by a questionnaire followed by medical examination and were selected or deferredbased on the guidelines laid down by Drugs and Cosmetics Act,1940 and Directorate General of Health Services,MoHFW,Govt of India1.2 .Data was collected using a proforma and analysed by SPSS software wherever indicated.Results: During this time period, 2611 donors registered for blood donation, out of which 425 donors were deferreddue to diverse reasons. Most of the donors were voluntary donors(98.3%) of which majority were males(86.4%).The commonest cause of deferral in males was high BP(24%) and high Hb(11.3%) whereas the commonest cause ofdeferrals in females was low Hb (46.9%). Most of the donors were rejected due to temporary reasons(97.1%). Thecommonest reason of permanent deferrals was a medical history of uncontrolled DM.

Evaluation of Efficacy of a Quality Improvement Haemodialysis Safety Checklist for Nursing Staff: A Comparative Analysis

Haemodialysis is a life-sustaining procedure performed on patients with end-stage renal disease. However, it is not without risks and patient safety during haemodialysis is of utmost importance. This research study aims to evaluate the efficacy of a quality improvement Haemodialysis Safety Checklist in enhancing patient safety and improving the performance of nursing staff. A comparative analysis approach was employed to assess the impact of implementing the Haemodialysis Safety Checklist. The study involved two groups: an intervention group where the checklist was implemented and a control group where the checklist was not introduced. Patients’ health records were assessed then to check the frequency of complications/ serious events and deaths. The results of the study showed that the implementation of a checklist had a positive impact on compliance and safety during the dialysis procedure. Before dialysis, only one participant (0.1%) did not comply with thermometer reading, while the majority, 749 (99.9%), followed the protocol. Similarly, 5 participants (0.7%) did not undergo weight checks before dialysis, which decreased to four participants (0.5%) after checklist implementation. In terms of vital signs, 35 participants (4.7%) did not have them checked before dialysis, while only two participants (0.3%) skipped them post-dialysis. Adverse events were minimal, with most participants not experiencing hypoglycaemic or hypotensive episodes, complications at the access site, requiring Renal Replacement Therapy (RRT) or encountering Code Blue situations, blood loss, falls, or needle stick injuries. The introduction of the checklist reduced the percentage of participants not having their weight measured after dialysis from 6.7% to 0.4%, with a statistically significant chi-square value ( &lt;0.001*). Similarly, the occurrence of cramps decreased from 99.7% to 98.9% after dialysis. These findings demonstrate the checklist’s effectiveness in improving compliance and reducing adverse events during dialysis.

Scalp Cooling to Prevent Hair Loss in Multiple Myeloma Patients Undergoing Autologous Peripheral Blood Stem Cell Transplantation

The best outcomes for multiple myeloma progression-free and overall survival include the use of high-dose melphalan and autologous peripheral blood stem cell transplantation. Melphalan is given at a dose of 140 - 200 mg/m2 as a single dose two days before or in divided daily doses immediately prior to the reinfusion of stem cells. Melphalan causes nearly complete hair loss in all patients at these doses, (CTCAE v5 Grade 2). Hair typically falls out after 10-15 days and doesn't begin to grow back for 10-12 weeks. This outcome is widely expected and leads some patients to avoid doing an otherwise life sustaining procedure. In those that do proceed with the transplant, the alopecia can be emotionally harmful. Cryotherapy is commonly used to reduce melphalan side effects in the GI tract. Melphalan typically will cause diarrhea, nausea, and mouth sores yet a randomized trial done in 2006 showed that swallowing ice chips for 6 hours starting 30 minutes before the melphalan is given can reduce these unpleasant and potentially dangerous side effects by 60% (Lilleby et. al. 2006). We at Cedars-Sinai routinely have patients do oral cryotherapy for 3.5 hours starting 30 minutes prior to each dose of melphalan. This has reduced patient side effects substantially in our experience and is considered our standard of care. Chemotherapy drugs, such as melphalan, typically injure bone marrow, intestinal lining and other cells with high metabolism and rapid cell division. Hair follicles also have these properties and is likely why many chemotherapeutics cause hair loss when used. Scalp cooling has been used to prevent hair loss in many patients undergoing chemotherapy for solid tumors. For some women with breast cancer, this hair loss was reported to be more traumatizing than losing a breast to mastectomy (Zhang et. al. 2022). The use of cold caps during chemotherapy exposure time has helped reduce hair loss, presumably by causing vasoconstriction and reducing distribution of the drug to the hair follicle. This intervention has been effective even when drugs which have longer durations of circulation have been given. While there is a theoretical risk that scalp cooling may impair the killing of malignant cells in the scalp by the chemotherapy, there is no evidence of a heightened risk in studies. The penetration of the cold should not reach the skull bone where myeloma cells may reside and is generally to a depth of only a few millimeters. The toxicity of scalp cooling is minimal. In a study of 27 participants using scalp cooling for solid tumors, 96% reported that the procedure was worth the time, effort, cost, and discomfort and would recommend usage to others undergoing the same chemotherapy treatment (Sitarz et. al. 2022). While scalp cooling has been used to prevent hair loss in patients undergoing chemotherapy for solid tumors, no reports were found for its usage for multiple myeloma or other hematologic malignancies. Since melphalan has a much shorter half-life, (70 minutes), than most other chemotherapy drugs used for solid tumors, it is anticipated that scalp cooling will be more efficacious when used with this drug. In fact, after 5 hours the concentration of melphalan should only be 5% of that present immediately after administration. A 57-year-old patient with multiple myeloma undergoing high-dose chemotherapy with melphalan 200 mg/m2 opted to use the commercially available Penguin Cold Cap to prevent losing her hair. The device was started 60 minutes before and continued for 5 hours after the melphalan infusion was started at Day -2 and Day -1 prior to her autologous stem cell transplant. The procedure was well tolerated, and the patient had no signs of any hair loss after the stem cell transplant. Based upon this experience, a study was initiated to further assess the efficacy of scalp cooling with the Penguin Cold Cap device in multiple myeloma patients receiving autologous stem cell transplants. An update with results of this study will be presented at the meeting. A positive outcome may improve the percentage of people willing to undergo this life-sustaining procedure and improve the quality of life of those who do it.

An Assessment Of The Ethical And Legal Dilemma In The Practice Of Anaesthesiology: The Nigerian Perspective

The practice of medicine intersects with the legal system in two important ways. The ethical code establishes the framework of permissible conduct, through regulation, while the legal system provides patients and other entities recourse when these regulations are breached. Anaesthesia is a branch of Medicine and Anaesthesiologists care for patients at the extremes of health and illness, frequently employing life-sustaining technologies and procedures to restore health. Patients have widely recognised right to reject life-sustaining procedures that may be in conflict with the tradition of physician paternalism and authoritarianism derived from virtue-based ethics. This naturally leads to high expectations among the general public from the Anaesthesiologists. In the past, patients used to subject themselves to surgery after signing a simple willingness form, but in the present scenario, if any catastrophe occurs, it grabs news headlines, negligence is suspected by the general public. There has been a rising trend in medical negligence cases that the services provided by an anaesthesiologist come under the apprehension standard of care, protocols by which anaesthesiologists should abide to avoid legal consequences. This paper examines emerging ethical issues since the establishment of anaesthesia as a branch of medicine. The paper adopts the doctrinal methodology of research by examining primary and secondary sources related to the discourse. The paper further recommends adequate medical information by way of educating patients on their rights before any medical procedure among others.

Solving problems in Blood transfusion with efficient technology

Blood transfusion is a life-sustaining procedure. But there are several hurdles in safe blood administration which can cause transfusion transmitted infections (TTI) and acute transfusion reactions and even death. Besides, human errors anywhere in the transfusion chain add fuel to the fire. Blood borne Infections like Hepatitis B and Hepatitis C are highly prevalent in Pakistan affecting about 7.4% of the general population. Among acute transfusion reactions, Febrile nonhemolytic reaction and the allergic reaction are the most common. Moreover, a variety of human errors and near-miss events in transfusion have been reported in the past. Technology has played an important contribution in upgrading the quality of life and healthcare. The main goal of this review is to point out the problems in blood transfusion and to hint at possible solutions with the use of Technology. In addition to following the WHO strategies for safe blood transfusion, blood safety can be ensured by incorporating haemovigilance systems, pathogen reduction technologies and certain approaches to reduce the risk of bacterial contamination. Human errors can be halted via a Management Information System called “Blood Bank Management Information System (BBMIS)” which can recognize and arrest such errors simultaneously.

Palliative Care and Life-Sustaining/Local Procedures in Colorectal Cancer in the United States Hospitals: A Ten-Year Perspective.

BackgroundIn recent years, palliative care utilization has been increasing while life-sustaining/local procedures have been declining at the end of life. Palliative care utilization widely varies based on tumor type. Limited information is available on inpatient palliative care in colorectal cancer.AimsThis study investigated inpatient palliative care utilization and its association with patient demographics, hospital charges, and procedures among colorectal cancer patients admitted to US hospitals between 2008 and 2017. Receipt of life-sustaining and local procedures and surgeries were also investigated during the ten years.MethodsData were extracted from the National inpatient sample (NIS) database containing de-identified information from each hospitalization. Codes V66.7 for ICD-9-CM or Z51.5 for ICD-10-CM were used to find palliative care utilization. Data were analyzed using generalized regression with adjustment for variations in predictors. The Compound Annual Growth Rate (CAGR) was calculated for palliative care and procedures over time.ResultsOf the 487,027 colorectal cancer hospitalizations, only 6.04% utilized palliative care. This percentage significantly increased over time from 2.3% in 2008 to 9.3% in 2017 (P<0.0001). Palliative care utilization sizably decreased hospital charges by $18,010 per hospitalization (P<0.0001) and was positively associated with female gender, severe disease, and age over 80 years (P≤ 0.05). Palliative care utilization was inversely associated with using life-sustaining and local procedures and surgeries (P<0.0001). Life-sustaining procedures (intubation, infusion of concentrate nutrients, dialysis, and blood transfusion) and surgeries were decreased over time (P<0.001).ConclusionsPalliative care utilization increased over time and was inversely associated with hospital charges and performing procedures among colorectal cancer patients. Our findings warrant further research and interventions to increase palliative care utilization in colorectal cancer.

Population Pharmacokinetic Modeling and Simulations of Imipenem in Burn Patients With and Without Continuous Venovenous Hemofiltration in the Military Health System

Continuous venovenous hemofiltration (CVVH) is a life‐sustaining procedure in patients with severe burns and acute kidney injury. Physiologic changes from burn injury and use of CVVH may alter imipenem pharmacokinetics (PK). We aimed to compare imipenem clearance (CL) in burn patients with and without CVVH, determine the effect of burn on imipenem volume of distribution (CVVH, n = 12; no CVVH, n = 11), in combination with previously published models. Model qualification was performed with standard diagnostics and comparing predicted PK parameters/time‐concentration profiles with those in the existing literature. Monte Carlo simulations were conducted to evaluate the probability of target attainment. A 2‐compartment model best described the data. Utilizing albumin as a covariate on volume parameters and leveraging the clearance model from prior literature, our model predicted imipenem central volume and CL within a 10% margin of error across healthy, renally impaired, and burn populations. We provide direct comparison of imipenem CL in burn patients with and without CVVH. Notably, there was no significant difference. Large imipenem Vd in patients with severe burns is likely explained by increased capillary permeability, for which serum albumin may be a reasonable surrogate. Dosing 500 mg every 6 hours is adequate for burn patients on renally dosed CVVH; however, suspicion of augmented renal clearance or patients placed on CVVH without renal impairment may necessitate dosing of 1000 mg every 6 hours.

Differences in end-of-life care and outcomes in palliative consultation-eligible patients with and without do-not-resuscitate orders: A propensity score-matched study.

The primary objective of palliative care, not synonymous with end-of-life (EOL) care, is to align care plans with patient goals, regardless of whether these goals include the pursuit of invasive, life-sustaining procedures, or not. This study determines the differences in EOL care, resource utilization, and outcome in palliative care consultation-eligible emergency department patients with and without do-not-resuscitate (DNR) orders. This is a retrospective observational study. We consecutively enrolled all the acutely and critically ill emergency department patients eligible for palliative care consultation at the Taipei Veterans General Hospital, a 3000-bed tertiary hospital, from February 1 to July 31, 2018. The outcome measures included in-hospital mortality and EOL care of patients with and without DNR. A total of 396 patients were included: 159 with and 237 without DNR. Propensity score matching revealed that patients with DNR had significantly shorter duration of hospital stay (404.4 ± 344.4 hours vs 505.2 ± 498.1 hours; p = 0.037), higher in-hospital mortality (54.1% vs 34.6%; p < 0.001), and lower total hospital expenditure (191 239 ± 177 962 NTD vs 249 194 ± 305 629 NTD; p = 0.04). Among patients with DNR, there were fewer deaths in the intensive care unit (30.2% vs 37.0%), more deaths in the hospice ward (16.3% vs 7.4%), more critical discharge to home (9.3% vs 7.4%), more endotracheal removals (3.1% vs 0%; p = 0.024), and more narcotics use (32.7% vs 22.1%; p = 0.018). The palliative care consultation-eligible emergency department patients with DNR compared with those without DNR experienced worse outcomes, greater pain control, more endotracheal extubations, shorter duration of hospital stay, more critical discharge to home, more hospice referrals, and 23.3% reduction in total expenditure. There were fewer deaths in the ICU among them as well.

A Rare Case of Perinatal Hypophosphatasia Treated With Asfotase Alfa

Background: Perinatal Hypophosphatasia (HPP) is a rare and lethal disorder associated with a 50–100% mortality rate, usually due to respiratory complications. HPP occurs due to a loss-of-function mutation in the ALPL gene, responsible for the function of tissue-nonspecific alkaline phosphatase (TNSALP). Clinically, HPP presents as a severe lack of bone mineralization leading to a rickets-like presentation. Clinical Case: A 4-month-old female presented from an outside hospital for the ongoing care of perinatal HPP. Prenatal scans with long-bone fractures raised concern for Osteogenesis imperfecta. However, alkaline phosphatase (ALP) at birth was <11 U/L, and vitamin B6 was elevated >250 ng/mL. Calcium, 25-OH vitamin D, and urine phosphoethanolamine were normal. A genetics panel for HPP confirmed two pathogenic autosomal recessive mutations on the ALPL gene.Treatment with asfotase alfa 3 mg/kg three times weekly was started on day two of life. The clinical course has been complicated by the need for mechanical ventilator support, seizure-event shortly after birth, recent EEG demonstrating epileptogenic potential in the bitemporal cortical regions now on treatment with Keppra, possible craniosynostosis with mild-to-moderate ventriculomegaly, and minimal grade 1 medullary nephrocalcinosis. Bone mineralization is monitored via skeletal surveys, and changes are measured using the Radiographic Global Impression of Change (RGI-C) and the Rickets Scoring Scale (RSS). After four months of asfotase alfa treatment, substantial progress in bone mineralization per RGI-C scoring has been noted, but RSS scoring still indicates severely low bone mineralization. ALP remains >3,000 U/L. Calcium, 25-OH vitamin D, and vitamin B6 are normal. Careful monitoring with weekly biochemical and urine profiles and monthly skeletal surveys, neuro assessments, and renal ultrasounds are ongoing. Conclusions: This clinical case demonstrates the improvement in bone mineralization with asfotase alfa, but the clinical course is slow and arduous. Despite the early initiation of asfotase alfa the patient’s bone mineralization remains severely low and is not in a safe range to proceed with G-tube, broviac, or tracheostomy placement. The current management goal is to maximize bone mineralization in preparation for the life-sustaining procedures mentioned above. With only a handful of surviving cases in the world, current long-term survival and outcomes for patients with perinatal HPP are unclear.

Trends in palliative care and life-sustaining procedure provision for patients with cervical cancer in the United States

Trends in palliative care and life-sustaining procedure provision for patients with cervical cancer in the United States

Teaching Without Harm: The Ethics of Performing Posthumous Procedures on the Newly Deceased.

Physicians must be proficient in and efficient at various lifesaving and life-sustaining procedures. Multiple methods exist to teach these skills to inexperienced medical professionals, ranging from lectures to practical models to live patients. Proficiency and prior knowledge are especially important when novice medical trainees first perform these procedures because of the increased risk of harm in these high-stakes scenarios. To mitigate inherent risks, many medical centers controversially advocate and allow the use of newly deceased patients to practice, teach, and perfect these procedures. As a result, this type of experience facilitates medical training and competency while simultaneously avoiding physical harm to living patients. Nonetheless, it raises numerous ethical and legal considerations, including concerns of damage to the doctor-patient relationship.This manuscript aims to comprehensively review the ethicality of practicing postmortem procedures and its current debate regarding the role and type of consent. This is followed by examining scenarios where the prior patient or postmortem surrogate consent is required for procedures that do not benefit the patient, including organ donation, cadaver donation, and brain tissue donation. Using these scenarios as a framework, best practices for gaining permission to use the newly deceased for medical training purposes are offered.Procedures on deceased patients should always be done under competent supervision in a structured manner, with comprehensive explanations to encourage accountability and professionalism and prevent misuse. Informed consent for all educational procedures must be obtained by individuals separate from the treatment team. However, exceptions to this standard could be made in pediatrics (especially in the neonatal intensive care unit) given the intimate relationship between providers and parents. Depending on the situation, consent should be obtained from the patient and/or their family, with separate documentation provided to create awareness. All relative parties should be consented after receiving appropriate time to process to prevent further emotional compromise. If there are concerns about jeopardizing the family and creating further burdens, they should not be approached.

A critical review of recent advances in hemodialysis membranes hemocompatibility and guidelines for future development

Hemodialysis is a life-sustaining procedure for patients with end-stage renal disease (ESRD). The efficiency of hemodialysis is limited by the dialysis membrane biocompatibility and the poor clearance of middle-molecule uremic toxins. As a result, hemodialysis is associated with acute chronic side-effects that threaten patients' lives. During hemodialysis, interfacial interactions of blood-polymeric membranes result in several consequences. These interactions lead to the body's various system activations, including the coagulation of blood components, leukocytes (i.e., immune system activation) and complement activations, thrombogenesis, cytokine production, and appearance of radicals with free oxygen. Despite advances in research, the most vital issue in dialysis therapies is the biocompatibility and hemoincompatibility of the membranes. The process of enhancing membrane hemocompatibility is currently posing a global challenge. Reactions to incompatibility can cause severe injuries to the patients and result in morbidity and mortality. This critical review offers a focused analysis of the latest efforts to enhance the hemodialysis membrane's hemocompatibility as well as emphasize current research gaps. Recent innovations (since 2014) in hemodialysis membranes are analyzed in correlation to categories of modified polymer structure chemistry tuning, and surface modifications and their influences on membrane hemocompatibility. Particular attention is paid to: (1) chemical immobilization of functional groups (surface grafting); (2) layer-by-layer chemical attachment of species (LBL); (3) covalent attachment of super hydrophilic-hydrogel; (4) mixed matrix membranes (MMM); and (5) base polymer membrane modification (blending method). This critical review provides an overview of the effects the modification methods can have on biocompatibility and how they can pave the way for optimum enhancement of hemodialysis membrane biocompatibility.

Regrets of family caregivers in Israel about the end of life of deceased relatives

Objective: We aimed to clarify the content of different types of regrets or lack of regret, and the frequency of feeling regret among family caregivers who assisted their relatives during their end of life stage.Method: Seventy primary informal caregivers in Israel were interviewed (17 spouses, 52 children, and 1 cousin) concerning their regret about the end of life of their deceased relative, including a general question about regret and questions about regret concerning life-sustaining treatments. After calculating the frequency of regrets and lack of regret, we conducted a qualitative analysis, using a thematic approach to identify themes and interpret data.Results: A majority of caregivers (63%) expressed regret and about 20% expressed ambivalence involving both regret and denial of regret. Regrets pertained to care given, suffering experienced, and the caregiver's behavior towards, and relationship with the deceased, including missing opportunities to express love and caring toward relatives. Caregivers viewed almost 30% of 75 administered life-sustaining procedures as misguided. Most regrets involved inaction, such as not communicating sufficiently, or not fighting for better care.Conclusion: This article provides a comprehensive description of EoL regrets, and helps clarify the complexity of regrets, lack of regrets, and ambivalence concerning regrets, though the study is limited to one country. Analysis suggests the need for public education concerning the EoL process, and for changes within the health care system to improve communication, to improve understanding of the needs of the terminally ill, and to provide more instruction to family caregivers to help them understand EoL.

Electronic Health Record-Embedded Decision Support Platform for Morphine Precision Dosing in Neonates.

Morphine is the opioid most commonly used for neonatal pain management. In intravenous form, it is administered as continuous infusions and intermittent injections, mostly based on empirically established protocols. Inadequate pain control in neonates can cause long-term adverse consequences; however, providing appropriate individualized morphine dosing is particularly challenging due to the interplay of rapid natural physiological changes and multiple life-sustaining procedures in patients who cannot describe their symptoms. At most institutions, morphine dosing in neonates is largely carried out as an iterative process using a wide range of starting doses and then titrating to effect based on clinical response and side effects using pain scores and levels of sedation. Our background data show that neonates exhibit large variability in morphine clearance resulting in a wide range of exposures, which are poorly predicted by dose alone. Here, we describe the development and implementation of an electronic health record-integrated, model-informed decision support platform for the precision dosing of morphine in the management of neonatal pain. The platform supports pharmacokinetic model-informed dosing guidance and has functionality to incorporate real-time drug concentration information. The feedback is inserted directly into prescribers' workflows so that they can make data-informed decisions. The expected outcomes are better clinical efficacy and safety with fewer side effects in the neonatal population.

Health Care Utilization and End-of-Life Care Outcomes for Patients With Decompensated Cirrhosis Based on Transplant Candidacy

ContextPatients with decompensated cirrhosis have high rates of health care utilization at end of life (EOL). However, the impact of transplant candidacy on intensity of EOL care is currently unknown. ObjectivesTo assess the relationship between transplant candidacy and intensity of EOL care in the last year of life in an ambulatory cohort of patients with decompensated cirrhosis. MethodsWe performed a retrospective analysis of 230 patients with decompensated cirrhosis who were evaluated for liver transplantation in a large health care system between 1/1/2010 and 12/31/2017 and died by 6/20/2018. We compared health care utilization in the last year of life and EOL care outcomes between transplant-listed (n = 133) and nonlisted (n = 97) patients. We examined predictors of palliative and hospice care utilization using multivariate logistic regression. ResultsDuring the last year of life, patients had a median of three hospitalizations (IQR 2–5) and spent a median of 31 days (IQR 16–49) in the hospital. In all, 80% of patients died in the hospital, with 70% dying in the intensive care unit. The majority (70.0%) received a life-sustaining procedure (mechanical ventilation, renal replacement therapy, or cardiopulmonary resuscitation) during their terminal hospitalization, which did not differ between transplant-listed and nonlisted patients (74.4% vs. 63.9%, P = 0.09). Transplant-listed patients had lower odds of receiving specialty palliative care (odds ratio 0.43, P = 0.005). Patients with hepatocellular carcinoma had higher odds of receiving hospice care (odds ratio 2.03, P = 0.049). ConclusionPatients with decompensated cirrhosis had intensive health care utilization during their last year of life regardless of transplant candidacy. Further work is needed to optimize their EOL care, particularly for patients who are ineligible for transplantation.

Trends in the Utilization of Life-Sustaining Procedures and Palliative Care Consultation Among Dying Patients With Advanced Chronic Pancreas Illnesses in US Hospitals: 2005 to 2014.

Pancreas cancer continues to carry a poor prognosis. Hospitalized patients with advanced chronic pancreatic illnesses increasingly receive palliative care due to its perceived clinical benefits. Meanwhile, a growing proportion of elderly patients are reportedly receiving life-sustaining procedures. Temporal trends in the utilization of life-sustaining procedures and palliative care consultation among dying patients with advanced chronic pancreatic illnesses in US hospitals were examined. A serial, cross-sectional analysis was carried out using the National Inpatient Sample Database. Decedents 18 years and older with a principal diagnosis of pancreas cancer or other advanced chronic pancreatic illnesses from 2005 through 2014. The compound annual growth rates (CAGRs) and Cochrane-Armitage correction of χ2 statistic were used. The receipt of life-sustaining systemic procedures, intra-abdominal local procedures and surgeries, and palliative care consultation were examined. Multilevel multivariate logistic regressions were performed to examine the association of various procedures with the utilization of palliative care consultation. Among 77 394 183 hospitalizations, 29 515 patients were examined. The CAGRs of systemic procedures, intra-abdominal procedures, surgeries, and palliative care were -4.19% (P = .008), 2.17%, -1.40%, and 14.03% (P < .001), respectively. The receipt of systemic procedures (odds ratio [OR] = 2.40, 95% confidence interval [CI], 2.08-2.74), local intra-abdominal procedures (OR = 1.46, 95% CI, 1.27-1.70), and surgeries (OR = 2.51, 95% CI, 2.07-3.05) was associated with palliative care consultation (Ps < .001). Among adults with pancreatic cancer or other advanced chronic pancreatic illnesses in the US hospitals from 2005 to 2014, the utilization of life-sustaining systemic procedures decreased while the prevalence of palliative care consultation increased.